Die Perforation stellt die häufigste und gefährlichste Komplikation der Sigmadivertikulitis dar. Der weitere Verlauf wird entscheidend durch das gewählte Therapiekonzept beeinfluβt. Dabei steht neben der chirurgischen Therapie die intensivmedizinische Behandlung im Vordergrund. Als determinierende Faktoren kommen der Sepsis und der Peritonitis eine besondere Bedeutung zu. Die frühzeitige operative Intervention, die intensivmedizinische Behandlung und die spezifische Therapie der Peritonitis und der septischen Komplikationen dieses gravierenden Krankheitsbildes sind von gröβter Bedeutung in der Behandlung der schwerkranken Patienten. Dennoch geht diese Erkrankung auch unter dem Einsatz aller Mittel noch mit einer hohen Letalität einher

A perforation is the most common complication in diverticulitis of the sigmoid colon. The clinical course of the disease is critically influenced by the medical treatment. The surgical therapy is a major point beside the accompanying intensive-care treatment. Septic disease and peritonitis are determinating factors. The early surgical intervention, the intensive-care treatment, a specific therapy of the peritonitis and the prevention of septic complications are most important in the successful treatment of these patients. Nevertheless this disease still shows, even under optimal therapeutic efforts, a high lethality rate.

The success of the laparoscopic cholecystectomy was remarkable and wellfounded, thus it seems necessary to examine whether this procedure could be also used for other general surgical operations. Since Dec. 29th, 1990 the transperitoneal repair of hernias by laparoscopy has been performed in 177 patients. The patients were followed up in regular intervals. The first 100 patients were treated with the ''plug repair'' technique of Schultz and Corbitt. In this group one recurrence (4 month after operation) and one dislocation of a mesh roll (2 weeks after the operation) were observed. In the middle of April 92 we changed the laparoscopic operation technique to a preperitoneal mesh fortification analogous to the procedure of Stoppa. This requires a detailed preparation of all possible positions of the hernia (medial and lateral compartment).A cutting through all layers of the abdominal wall can be avoided. After the preparation all abdominal wall defects can be fortified effectively and clearly. In this group we have treated 77 patients, so far without complications. With the exception of scrotal hernias and adhesions the laparoscopic hernioplastique can be used in any indication of inguinal hernia repair. An evaluation of the long-term results can only be performed in the future although the early results are encouraging.

Besides vagal cholinergic mechanisms, pancreatic polypeptide (PP) secretion is thought to be mediated by hormones. This study was performed to delineate the role of extrinsic pancreatic innervation and cholecystokinin (CCK) in amino acid- and fat-stimulated PP secretion. In ten mongrel dogs, pancreatic denervation was performed by the method of Debas et al. [3]. Total denervation of the pancreas did not alter PP response to intraduodenal application of amino acids (integrated output 24,434 +/- 3260 pmol/1 x 120 min before vs 22,797 +/- 2470 pmol/1 x 120 min after operation) and to intraduodenal fat solution (19,595 +/- 2121 pmol/1 x 120 min vs 19,983 +/- 2031 pmol/1 x 120 min). Also, no significant differences were measured in CCK release (491 +/- 71 pmol/1 x 120 min vs 430 +/- 57 pmol/1 x 120 min for amino acids, 571 = 63 pmol/1 x 120 min vs 563 +/- 89 pmol/1 x 120 min for fat solution). Plasma PP and CCK levels were compared by linear regression analysis. Correlations between PP and CCK were high in the intact pancreas (amino acids, r = 0.92; fat, r = 0.99) as well as in the denervated pancreas (r = 0.93 amino acids and r = 0.98 fat). These results show that extrinsic pancreatic innervation does not influence PP and CCK release after intraduodenal amino acids or fat solution and that PP secretion seems to be mediated to some extent through the release of CCK.

The success of the laparoscopic cholecystectomy was remarkable and well-founded, thus it seems necessary to examine whether this procedure could be also used for other general surgical operations. Since Dec. 29th, 1990 the transperitoneal repair of hernias by laparoscopy has been performed in 177 patients. The patients were followed up in regular intervals. The first 100 patients were treated with the "plug repair" technique of Schultz and Corbitt. In this group one recurrence (4 month after operation) and one dislocation of a mesh roll (2 weeks after the operation) were observed. In the middle of April 92 we changed the laparoscopic operation technique to a preperitoneal mesh fortification analogous to the procedure of Stoppa. This requires a detailed preparation of all possible positions of the hernia (medial and lateral compartment). A cutting through all layers of the abdominal wall can be avoided. After the preparation all abdominal wall defects can be fortified effectively and clearly. In this group we have treated 77 patients, so far without complications. With the exception of scrotal hernias and adhesions the laparoscopic hernioplastique can be used in any indication of inguinal hernia repair. An evaluation of the long-term results can only be performed in the future although the early results are encouraging.

The effect of hydroxyethyl starch on pancreas preservation with cardioplegic histidine-tryptophan-ketoglutarate solution (HTK) was investigated. The study was performed using an in vitro reperfusion system of the porcine pancreas. During organ preservation pancreatic weight, arterial pressure, volume flow, and washout of amylase and lactate were quantified. Addition of hydroxyethyl starch did not affect arteriovenous volume flow or washout of amylase and lactate during protective perfusion after pancreas preparation. However, hydroxyethyl starch in HTK prevented an increase in pancreatic weight at the end of the protective perfusion (102.2 ± 4.55% vs 127.8 ± 4.62% in controls; p < 0.005) and after 24 h cold ischemia (72.9 ± 3.91 % vs. 83.5 ± 3.49 % in controls; p < 0.05). Hydroxyethyl starch did not affect postischemic organ quality assessed during reperfusion in a perfusion chamber by pancreatic vascular resistance, amylase and lactate release, insulin secretion, and oxygen consumption. We conclude that hydroxyethyl starch does not bring about any further improvement in immediate postischemic organ quality assessed in an in vitro reperfusion system.

Im Dez. 1990 begannen wir die lap. Hernienchirurgie mit dem Plug & Patch-Verfahren (101 Hernien (H.)/88 Pat.; resorbierbares Material: 23, nicht resorbierbar: 78 H.). Im Febr. 1992 gingen wir zur anatomiegerechten präperitonealen Präparation über und legten zum spannungsfreien Verschluß Marlexnetz (10 × 5 cm/35 H. und später > 12 × 8 cm/123 H.) ein. Folgende Rezidive traten auf: Plug & Patch resorb.: 35%, nicht resorb.: 9%; „kleines“2 und „großes“Netz 0. Wir folgern, daß 1. die Plug & Patch-Methode der konventionellen Technik nicht überlegen ist, 2. der lap. präperitoneale Zugang einen spannungsfreien Verschluß in der richtigen Ebene ermöglicht und 3. die lap. präperitoneale Netzeinlage bisher gute Ergebnisse bei primären und Rezidivher-nien erbringt.

The present study compares the effect of organ preservation with Euro-Collins solution, cardioplegic histidine-tryptophan-ketoglutarate solution, and University of Wisconsin solution on immediate pancreatic function after cold storage at 4°C for 24 hr. Postischemic organ quality of a porcine pancreas preparation was tested by quantification of physiological and biomedical parameters in a one-line reperfusion system. During reperfusion with a constant arterial pressure the arteriovenous flow rate was significantly higher for HTK (5.7±0.91 ml/min, n=8; P<0.05 vs. EC) and UW (7.4 ± 0.81 ml/min, n=8; P<0.05 vs. EC) than for EC (3.0<0.26 ml/min, n=6). The lowest lactate content in the reperfusate was found after HTK protection (HTK, 64.0±7.2 μmol/50 ml, n=8; versus EC, 114.2 ± 1.7 μmol/50 ml, n=6, P<0.001; versus UW, 148.0 ± 28.6 μwnol/50 ml, n=8, P<0.05). Amylase in the venous effluent was significantly lower (P<0.05) for HTK or UW protection than for EC (HTK, 189×72.6 U/ml; UW, 188 ± 39.4 U/ml; EC, 416 ± 71.7 U/ml). Oxygen consumption during reperfusion was significantly higher for HTK (2.15 ± 0.22 μl/g/ min, P<0.001) and UW (1.80 ± 0.52 μl/g/min, P<0.05) than for EC (0.47 ± 0.13 μl/g/min). We conclude that immediate postischemic organ quality and pancreatic.

In the present study we examined the effect of extrinsic pancreatic denervation on meal-stimulated pancreatic exocrine secretion and the release of neurotensin and CCK in dogs. Denervation of the pancreas significantly decreased protein output from preoperatively 16,661 +/- 1824 mg x 150 min to 2033 +/- 316 mg x 150 min postoperatively (p less than 0.001), and bicarbonate secretion from 297.5 +/- 36 mmol x 150 min to 104.85 +/- 16 mmol x 150 min (p less than 0.01). Release of neurotensin and CCK was not altered by interruption of the extrinsic pancreatic nerves. Our findings are consistent with the hypothesis that pancreatic secretory response to a meal is predominantly mediated by neutral extrinsic reflexes.

In der vorliegenden Studic wurde der Einfluß des extrinsischen Nervensystems des Pankreas auf die exokrine Pankreassekretion nach Stimulation mit Sekretin, Zärulein, Tryptophan and Fett sowie die Aminosäure-und Fett-stimulierte Freisetzung von Neurotensin und CCK beim Hund untersucht. Die Denervation der Bauchspeicheldrüse führte zu keiner Veränderung der exokrinen Antwort auf Sekretin and Zärulein, dagegen bewirkte die Ausschaltung der extrinsischen Nerven eine signifikante Verminderung der Proteinantwort auf Tryptophan and Fett. Die Freisetzung von CCK wurde nicht verändert. Die Fett-stimulierten Neurotensinplasmaspiegel waren nach Denervation signifikant erhöht.

In the present study we examined the influence of extrinsic pancreatic innervation on exocrine pancreatic response to secretin, caerulein, tryptophan and fat, and furthermore the amino acid- and fat-stimulated release of neurotensin and CCK in dogs. Denervation of the pancreas did not alter secretory response to secretin and caerulein, whereas transsection of the extrinsic nerves significantly diminished the protein response to tryptophan and fat. Release of CCK was not altered by pancreatic denervation. However, fat-evoked neurotensin plasma levels were significantly increased after denervation of the pancreas.

In the present study we examined the influence of extrinsic pancreatic innervation on exocrine pancreatic response to secretin, caerulein, tryptophan and fat, and furthermore the amino acid- and fat-stimulated release of neurotensin and CCK in dogs. Denervation of the pancreas did not alter secretory response to secretin and caerulein, whereas transsection of the extrinsic nerves significantly diminished the protein response to tryptophan and fat. Release of CCK was not altered by pancreatic denervation. However, fat-evoked neurotensin plasma levels were significantly increased after denervation of the pancreas.

A laparoscopic procedure for surgical hernia repair is reported. In comparison to other methods we do not only remove the peritoneal sac, but close although the inguinal canal with a nonresorbable marlex mesh. Up to now we practiced this technique in 35 patients. First post-operative results are encouraging but nothing can be said about longterm results, especially the recurrence rate.

In the present study we examined the effect of extrinsic pancreatic denervation on meal-stimulated pancreatic exocrine secretion and the release of neurotensin and CCK in dogs.Denervation of the pancreas significantly decreased protein output from preoperatively 16 661 +/- 1824 mg x 150 min to 2033 +/- 316 mg x 150 min postoperatively (p < 0,001), and bicarbonate secretion from 297,5 +/- 36 mmol x 150 min to 104,85 +/- 16 mmol x 150 min (p < 0,01). Release of neurotensin and CCK was not altered by interruption of the extrinsic pancreatic nerves.Our findings are consistant with the hypothesis that pancreatic secretory response to a meal is predominantly mediated by neutral extrinsic reflexes.

In 10 dogs with pancreatic fistulas, we studied the effect of extrinsic pancreatic innervation and atropine on protein and bicarbonate secretion and cholecystokinin (CCK) release after intraduodenal perfusion with HCl. Before and after extrinsic denervation of the pancreas, the dogs were given 0.05 M HCl in increasing doses (1.5-48 mmol/h). Tests were repeated with atropine. Increasing doses of HCl resulted in a dose-dependent release of protein and bicarbonate output in both the intact and the denervated pancreas. However, pancreatic denervation significantly decreased pancreatic secretion in response to low loads but not to high loads of HCl. HCl-stimulated CCK release was not altered by pancreatic denervation. In the intact pancreas, atropine significantly reduced bicarbonate and protein response to low loads but not to high doses of HCl. In the denervated gland, atropine had no further inhibitory effect on exocrine pancreatic secretion. Furthermore, atropine showed no influence on HCl-stimulated CCK release under either condition.

The functional connection between the gut and the islet cells comprises nerves and gastrointestinal hormones. In this study, we quantified the incretin effect and the glucose tolerance (KG value) before and after denervation of the pancreas in dogs in order to find out whether the incretin effect is mediated by nerves. The participation of nerves was estimated by comparing metabolic tests before and after total extrinsic pancreatic denervation in 10 dogs. Fifty-nine percent of the insulin response after intragastric glucose was calculated preoperatively to be the result of incretin factors, a value similar to the 62% found in the postoperative series (with denervated pancreas). The response of GIP to intragastric glucose was not significantly different between pre- and postoperative tests. The KG values pre- and postoperative were in the same range. From our data, we conclude that extrinsic nerves of the pancreas do not seem to play an important role in mediating glucose homeostasis in dogs.

Pancreatic polypeptide (PP) is a potent inhibitor of pancreatic exocrine secretion in vivo. The mechanism of pancreatic inhibition by PP is unknown, but the absence of PP receptors on pancreatic exocrine cells makes a direct effect of this hormone on the gland unlikely. In this study, we investigated the hypothesis that PP exerts its inhibitory effect via extrinsic neural pathways. Ten dogs with gastric and pancreatic fistulas were given an intravenous infusion of 250 ng/kg−1 h−1 secretion and 50 ng/kg−1 h−1 caerulein over 3 h. One hour after starting the infusion, 400 pmol kg−1 h−1 porcine PP were administered over 1 h. Pancreatic bicarbonte and protein secretions were measured. Later, the pancreas was extrinsically denervated. PP infusion decreased bicarbonate secretion in the intact gland by 47% and in the denervated pancreas by 57%. Protein secretion was diminished by exogenous PP by 31% in the intact and by 44% in the denervated pancreas. Despite pancreatic denervation, PP still exerted a significant inhibitory effect. Atropine infusion completely blocked the inhibitory effect of PP on caerulein-stimulated pancreatic protein secretion both in the intact and denervated pancreas and of secretion-evoked bicarbonate output in the denervated gland. We conclude that the inhibitory action of the hormone is not mediated via extrinsic neural pathways of the pancreas, but PP may exert its effect via intrinsic atropine-sensitive mechanisms.